Archive for January, 2013

Before writing about burn treatment, let’s touch briefly on the Brazil nightclub fire. I posted “Fires and Burns in Disasters – What Should We Know” on Saturday afternoon, including nightclub fires as a major cause of mass casualty burns. It felt eerily ironic to wake up Sunday morning and hear about this tragedy. (I also suspect an element of crowd crush – another topic I’ve covered – Scary Fact #3 – Crowd Crush.) It’s an unfortunate reminder that disasters happen anywhere, anytime (even in America – 4 of the worst nightclub fires occurred here). Preparedness is important – the true tragedy is that nightclub disasters are preventable.

Diagram of Brazil nightclub single exit

Diagram of Brazil nightclub single exit

So let’s talk about emergency assessment and treatment of burn victims. Obviously, emergency responders (and occasional volunteers) are the front line. But fire is not uncommon – it could happen around you! Would you know what to do? Equally important – would you know what not to do?


Always start with your ABCs – make sure victims have an Airway, are Breathing OK, and Circulation/pulses are present! Burn, trauma, chemical, medical – it doesn’t matter what the problem is. You always check ABC’s first.

Cool the burn

You need to remove tissue heat to keep burns from worsening. Use cool running water on the burned area – if not available, immerse the burn in cool water or use cool compresses. Don’t use ice. Don’t use cold water. Don’t get the rest of the body wet or cold!!! Burn victims are prone to dangerously low body temperature (hypothermia) – the 3rd most common cause of burn death. Cool the burn only for 5-10 minutes (exceptions are chemical burns which sometimes need prolonged flushing).

***Burn myth – Use ice on a burn for comfort. NOT! Ice might decrease pain, but also worsens tissue injury and drops body temperature!***

Remove jewelry and clothing

Take off all jewelry and piercings. The whole body could swell up over the next 24 hours – not just the burn area. Removing jewelry in advance is better than cutting it off. Take off clothing – burnt clothes might be toxic (burning wool makes cyanide!), plus you can check the patient more thoroughly. Wrap the victim completely in warm blankets or coats, uncovering the burned areas only for treatment. Consider a heated car for warmth.

Rule of 9s for estimating burn body surface area.

Rule of 9s for estimating burn body surface area.

Estimate the amount of body surface area that is burned

Burn severity and urgent need for treatment is largely predicted by the percent of body surface affected by burns (see burn center admission criteria in my last post). The “Rule of 9’s” says one entire arm and hand is 9%. The head is 9%. One entire leg is 18%. The front of the trunk is 18%, and the back of the trunk is another 18%. The groin is 1% (equaling 100% total). A second rule helps for smaller burns. The victim’s palm size is 1% – estimate how many palms it takes to equal the burned area. (Kids have different rules but unfortunately no time to cover that).

If the body is 90% burnt, the patient will not survive (triage black). If 40-90% burnt, they will survive only with a ventilator and intensive care level burn treatment. Without these resources, they will also be black.

How deep are the burns?

Numbered burn stages are out of vogue. Instead, we describe burns by depth of tissue injury:

  • Superficial (old stage 1) is the sunburn equivalent, affecting only the outer most layer of skin, with redness and variable pain (as my fair Irish skin attests to!).
  • Superficial partial thickness burns (old stage 2) appear red, wet, blistered and very painful.
  • Deep partial thickness burns (also old stage 2) destroy skin structures such as oil and sweat glands. They look blotchy red and white, moist, but not blistered or wet, and are painful. Redness whitens with pressure, reddening again very slowly.
  • Full thickness burns (old stage 3) involve all skin levels. The wound appears dark red, white, leathery brown, or black. Nerve destruction means there is NO PAIN. (Full thickness always needs skin grafting.)
  • Burns extending into muscle or bone are bad news (stage 4). Burns appear charred and blackened. Survivors often require amputation.

You can’t always know burn depth for several days. Burn appearances can be deceiving, plus burn injuries often deepen, particularly in malnourished patients, the old or very young, and the chronically ill. In the field, just make your best estimate – like always! Remember burn pain is good – it means nerves are alive (not full thickness).

Where are the burns?

Practicing intubation on a mannequin.

Practicing intubation on a mannequin.

Severe burns of the face, head, and upper chest suggest probable upper airway burns as well. These patients need emergency intubation (an important word, meaning placement of an airway tube) before their throat swells up and they stop breathing! This delayed swelling can happen even when breathing seems OK at first.

Full thickness burns completely encircling an arm or a leg sometimes block circulation. Watch for deep tissue pain, progressive numbness, decreased pulses, and cyanosis (blueness) below the burn. Keeping the burned limb elevated and doing range of motion might help circulation and decrease swelling. Similar burns circling the chest can block chest expansion for breathing. Emergency incisions (escharotomy) through the burn can restore circulation or breathing (don’t worry – we don’t expect non-medical helpers to go this far). Burns of the face, hands, feet, groin, or major joints also need special care to prevent permanent impairment.

Remember different body areas might have different burn severity – look everywhere. Consider sketching a body diagram and marking burns.

What caused the burns?

Burns can be thermal (scald, flame, heat), chemical, electrical, or blast. Some pose unique problems. Electricity causes delayed hidden damage, and not always at the contact spot. Problems include scattered burns where electricity leaves the body, brain damage, massive tissue breakdown with kidney failure, and even respiratory arrest. Chemical burns require decontamination by teams in crazy Haz-Mat suits – always keep chemicals away from responders.  It sometimes takes a day or two for full chemical burns to appear. Explosions cause internal blast injuries and trauma in addition to burns.

Inhalation Injury

Smoke inhalation is the most common reason for fire death, with many victims never escaping the building. Hot smoke kills by a combination of airway burns, lung irritation and swelling, and poisoning from carbon monoxide, cyanide, and other chemicals. Carbon monoxide poisoning is hard to recognize. Victims are not cheery red (like I was taught), nor are they cyanotic (blue). Just assume that smoke inhalation and carbon monoxide poisoning go hand in hand. Intubate victims and treat with 100% oxygen as soon as available.

Delayed inhalation injuries can develop over 24 hours. Watch all fire victims (even without face and chest burns) for warning signs, such as noisy breathing, sooty sputum, increased breathing effort, and trouble swallowing. With both upper airway burns and lower airway inhalation injury, patients will die if they are not intubated before problems start.

7-year-old Afghan boy has his burn wounds re-bandaged.

7-year-old Afghan boy has his burn wounds re-bandaged.

Burn Wound Care

Burn infection is a big concern – keep burns covered with a dry clean cloth until ready to bandage. Set up everything in advance – soap, water, gauze, bulky bandages (if not available, use clean cloth strips), and pre-cut tape. Uncover only one burn area at a time. Gently rinse the burn with water. Use mild soap if the wound is dirty. Don’t scrub – just remove obvious dirt.

**Burn Myth –Peel or pick tar or other contaminants off gently. NOT! NEVER pull or pick on things stuck to a burn. Try rinsing off with water. If unsuccessful, mineral oil or Vaseline dressings gradually dissolve even tar, allowing it to gradually come free over several days.**

Once the burn is clean, apply an ointment, either directly to the burn or on the bandage. Keep the burn moist. Prescription Silvadene is recommended for deep partial and full thickness burns (very expensive). Use over-the-counter double antibiotic ointments for superficial partial burns, and or when Silvadene is not available (bacitracin and polymyxin B without neomycin – it has a higher chance of allergic reaction). If all else fails, good old-fashioned Vaseline works for burn field treatment.

***Burn myth – Use butter on burns. NOT! Butter and oils increase infection risk. Never use them!***

Place a bulky bandage with ointment on the burn, then wrap loosely with gauze or cloth strips, starting further out on the limb and moving in. Watch closely as swelling develops – don’t let wraps get tight!

***Burn myth – Saran Wrap is a good burn wrap. NOT! It doesn’t stretch and could cut off circulation if swelling occurs.***

Common intravenous fluid for burns.

Common intravenous fluid for burns.

Fluid Problems

Large burns lose fluids as secretions. When generalized swelling develops, fluid also moves from the blood stream into tissues, causing low blood pressure and shock. Intravenous fluid replacement with close monitoring is best, but until available, at least encourage oral fluids. Some even give fluids rectally.

There you have it  – basic burn treatment. It’s a tad bit more complicated than many first aid and field treatments. I find it fascinating (what can I say – I’m a doctor!), but I hope you never have to treat burns. But in case you do, let me summarize:

  • ABCs
  • Cool the burn but keep the patient warm
  • Determine body surface area and location burned
  • Watch breathing and intubate early
  • Give plenty of fluids
  • Dress burns with ointment and clean bandages

Oh – and pray for quick hospital or burn center transport, before complications set in and things get really tricky!

Stay safe,

Sheila Sund, M.D.

Addendum 2-5-13: In discussing wound care and ointments above, I need to clarify. If you have access to medical care that day, you shouldn’t use an ointment or product of any type. Just cool the burn, clean, cover with a clean dressing to prevent further contamination, keep the patient warm, and get to the emergency room. However, in a situation where medical care will be significantly delayed, then using Silvadene or antibiotic ointment (or Vaseline as a last resort) is indicated to protect from infection and to keep the wound bed moist until definitive care is available.